Archive for the ‘Specific psychiatric disorders’ Category

Also know as erotomania, De Clérambault’s syndrome is one in which a delusional belief is held by a patient that another person, usually older and of higher social status, famous, wealthy or in a professional relationship with the patient is deeply in love with them.

Pursuing the object of their affections and repeatedly pestering them by telephone, by letter and with gifts is typical. Some people suffering from this disorder arrange ‘holidays’ or ‘weddings’ with their supposed lover.

Key features are:

The conviction of being loved

Supposed lover does nothing to encourage or sustain the belief, usually making clear their lack of interest or concern

Words or actions of supposed ‘lover’ are reinterpreted to maintain belief in requited love

Belief that supposed relationship will eventually result in a permanent and loving relationship

Preoccupations with supposed love form a central part of the subject’s existence.

Repeated attempts to approach the supposed lover creating at least embarrassment and distress.

The condition is rare and has various aetiologies; it can surface in association with schizophrenia or affective disorders, or on its own as a single delusional disorder. It is seen in forensic populations as a result of criminal acts secondary to the delusion and is one of a number of behaviours that may be associated with stalking.

The disorder is named after French psychiatrist Gaëtan Gatian de Clérambault (1872–1934), who published a review paper on the subject (Les Psychoses Passionelles) in 1921. The syndrome has featured in popular works, perhaps the best well know of which is Ian McEwan’s Enduring Love. It is thought to have effected John Hinckley, Jr. who shot President Regan in 1981 in an attempt to impress actress Jodie Foster, who he believed wanted a sign of his devotion.

Capgras syndrome is one in which a patient has a delusional belief that a person or persons, usually well known to them, have been replaced by an identical impostor(s). It usually occurs in the context of a psychotic illness (more than half of cases are associated with schizophrenia) but may be seen with other psychiatric illnesses, including brain injury or dementia.

The Capgras delusion is one of a number of delusional misidentification syndromes, a class of delusional beliefs that involves the misidentification of people, places or objects.

Joseph Capgras (1873-1950) was a French psychiatrist who first described the disorder in a 1923 paper co-authored with Reboul-Lachaux about the case of a French woman who complained that various ‘doubles’ had taken the place of people she knew. They called this ‘L’illusion des sosies’ (the illusion of doubles).

Current thinking as to the cause of Capgras syndrome has focused on dysfunction of the inferior temporal cortex and the amydala. The former is involved with recognising faces and the latter with the simultaneous emotional reaction. These two structures can be damaged independently; if the ability to recognise faces remains intact but the emotional reaction which makes them familiar is absent, it is hypothesised that the conculsion drawn will be that the person in question is an identical impostor.

Uncommon psychiatric syndromes – Enoch, Enoch and Ball – is an interesting book with chapters on this syndrome and others. I read it on holiday in Syria, which I think shows true dedication to my cause.

Up until the end of the 18th century mental disorders were divided into roughly four categories: idiocy (congenital intellectual impairment), dementia (acquired intellectual impairment), mania (insanity associated with many delusions and disturbed behaviour), and melancholia (insanity associated with circumscribed delusions and social withdrawal).

Morel in France was one of the first people to put forward the view that that mental disorders could in fact be further separated and classified. In 1852 he gave the name démence précoce to describe a disorder which he described as starting in adolescence and leading first to a withdrawal, odd mannerisms, self-neglect and eventually to intellectual deterioration.

Kraepelin working in the late nineteenth century took inspiration from general paralysis of the insane – a disease with unity of cause, course and outcome – and argued that there were a discrete and discoverable number of psychiatric disorders. He sought to distinguish between ‘dementia praecox’ and affective psychosis. Dementia praecox described patients with a global disruption of perceptual and cognitive processes (dementia) together with early onset (praecox). Affective psychosis contrasted with relatively intact thinking, later onset and episodic nature of the illness.

It was Bleuler who first used the phrase ‘schizophrenia’. It is commonly thought that this means ‘split personality’ but Bleuler actually meant the name to reflect the ‘loosening of the associations’; he thought this the essence of the disease. He described four fundamental symptoms which he deemed essential for the diagnosis: loosened associations (between different functions of the mind, so that thoughts become disconnected and co-ordination between emotional and volitional processes become weaker), ambivalence (the presence of conflicting emotions and desires), incongruous affect (e.g. vacuous giggling on hearing sad news), and autism (active withdrawal from reality in order to live in an inner world of fantasy)
Unlike Kraeplin, Bleuler felt that affective psychosis and schizophrenia were not strictly delineated but on lay on a continuum. He also demoted hallucinations and delusions, which to Kraeplin were central, to ‘secondary symptoms’.

More recently, working in the 1950s, Kurt Schneider’s work was fundamentally pragmatic. He lent on the earlier work of Karl Jaspers – a philosopher psychiatrist who had concentrated on the phenomenology of mental disorders, in particular the un-understandability of psychotic delusions – and aimed to identify characteristics that were peculiar to schizophrenia and which would therefore provide the best guide to the practising clinician. He identified eleven first rank symptoms of the disorder, all of which were forms of hallucination, delusion or passivity experience.

We can see from the above brief summary of the evolution of schizophrenia as an idea that what is central to the diagnosis has significantly altered as it has passed through the hands of these thinkers. For Kraepelin the crucial features were intellectual, for Bleuler cognitive and emotional, whereas Schneider pinpointed hallucinations and delusions. Their ideas are still important as DSM IV/ICD-10 criteria for schizophrenia are a patchwork of the ideas of all three. Therefore although operationalized criteria have improved the reliability of the schizophrenia diagnosis and outside psychiatry it is considered to be a crystallized entity, not only does there still remain no firm aetiology or diagnostic test for schizophrenia but its very character is still up for question.

(Although I’ve written this to be read without seeing the programme, it will inevitably be more interesting if you watch it as well. On Channel 4 | YouTube)

In ‘Half ton son’, a delicately titled television program shown on Channel 4 last Sunday night, 19-year-old Billy Robbins from Texas can’t move from his room because he weighs 60 stone. The programme follows him as he struggles into the ambulance that takes him to hospital, as the surgeons remove from him five stone of abdominal fat and then band his stomach, and then as he is eventually separated from his mother in recognition he is unlikely to continue to recover in her presence. How could such a thing happen?

In the film Billy and his mother are clearly ‘enmeshed’. Enmeshed families have members’ whose relationships are unusually tight and at their most extreme they are described as being able to read each other’s minds. Billy’s mother describes herself as Billy’s best friend, and she calls him her ‘baby’. Billy really still is her baby; his weight causes him so much disability that she not only feeds him (8000 calories a day), but also wipes his bottom. We don’t have to be psychoanalysts to see the roots of this; Billy’s older brother died before he was born, and in response she wishes to give Billy everything he needs, and that which she can no longer give her first born, whilst Billy – in his gluttony – seeks in vain to replace his dead brother.

Hand in hand with this enmeshment, the ‘boundaries’ between Billy and his mother are a mess. These boundaries are theoretical constructs that separate an individual from his or her surroundings. Our society is full of them and large part of growing up is learning where they lie. An example would be the inappropriateness, around here at any rate, of French kissing your mother-in-law. Boundaries within a family are of great interest to structural family therapists especially and can be thought of as rigid (leading to disagreement), clear (leading to autonomy) or permeable (a.k.a. fluid or undifferentiated) preventing family members from becoming autonomous.

Billy weight is clearly difficult problem to fix. And fascinating was the reaction of the healthcare professionals. Instead of tackling the root of the problem, the relationship between Billy and his mother, they preferred to tinker around the edge with a technological fix, an extremely risky stomach banding operation. And it’s of note that medical teams are involved at all; here then a demonstration of two cultural forces described by Ivan Illich in his book Medical Nemesis: social and cultural iatrogenesis. Social iatrogenesis is the medicalisation of life, and cultural iatrogenesis, the erosion of traditional ways of dealing with what have now come to be defined as medical problems*.

But, I was thinking on my cycle home today, what of this? What must it be like to be the ‘world’s heaviest teenager’ every day slowly eating yourself to death? Or his mother complicit in her son’s condition, driven by psychological impulses she only partially understands?

*Note that I described Billy’s weight as a problem to ‘fix’ as if he were a machine – these idioms are so ingrained that they are hard to avoid.

‘Internet addiction’ is in the news this week, as the authorities in China are threatening to recognize it as a clinical syndrome.It has steadily been accruing column inches of late having received a substantial profile boost in March when Dr Jerald Block suggested in an editorial American Journal of Psychiatry that it is a ‘common disorder’ and deserving of a place in the upcoming DSM-V.

It’s telling that internet addiction disorder (IAD) was originally proposed as a joke.In 1995 New York Psychiatrist Dr Ivan Goldberg decided to parody the complexities of DSM-IV by means of a disorder of his own invention, and was surprised when his bleary-eyed colleagues stepped forward as sufferers and asked him for help.Ironically in response Goldberg set up an online internet addiction support group.This apart, he remains a less than committed advocate.Here he is, talking to the New Yorker:

IAD is a very unfortunate term. It makes it sound as if one were dealing with heroin, a truly addicting substance that can alter almost every cell in the body. To medicalize every behavior by putting it into psychiatric nomenclature is ridiculous. If you expand the concept of addiction to include everything people can overdo, then you must talk about people being addicted to books, addicted to jogging, addicted to other people.

Although the rise and rise of the World Wide Web and its possible misuse is worthy of study and debate, I disagree with the classification of internet overuse as an ‘addiction disorder’.The concept contains so many holes, you could use it to strain pasta.

In a psychiatric sense ‘addiction’ is best applied to the use of psychoactive substances where it is described in terms of dependence syndrome.In brief: in order to keep us alive, the brain has evolved reward pathways which make us feel better about fundamental things that are in our interest, such as eating and sex.The trick that drugs such as heroin pull is to reward us in the same way for an activity that has no intrinsic value.Thus, for an individual, the taking of heroin then takes on a much higher priority than other behaviours, which once had a greater value.The presence of a withdrawal syndrome is also important.

An obsession with the internet shares few characteristics with a dependence syndrome. But this is only a small part of the folly of IAD. Framing overuse of the internet as a psychiatric condition, medicalises it and leads to us thinking about its treatment in terms of psychiatric interventions where more prosaic ones might be more appropriate.Here’s Block again, pen in one hand and in this other his prescription pad and section papers.

South Korea considers Internet addiction one of its mostserious public health issues.Using data from 2006, theSouth Korean government estimates that approximately 210,000South Korean children (2.1%; ages 6–19) are afflictedand require treatmentAbout 80% of those needing treatmentmay need psychotropic medications, and perhaps 20% to 24% requirehospitalization Am J Psychiatry 165:306-307, March 2008

You can almost hear the ambulance sirens.If something is sufficiently hazardous to require 1.6% of South Korea’s population of 6-19 year olds to take psychotropic medication, surely the authorities should think about banning it?And should we believe these figures?Block cites various symposia and reports, but little in the way of peer reviewed research.Any attempt to understand the natural history of internet overuse goes unmentioned.

Some of the strongest advocates for the IAD model are involved with selling addiction treatments and so cannot be regarded as unbiased. Dr Block owns a patent on technology that can restrict computer access.If we heed their advice mental health services will again recruit mildly dysfunctional people, for whom it can offer little help.More appropriate action would require looking into why some people appear more comfortable convening with a computer screen to the expense of other arguably more wholesome activities.I would not be at all surprised if provision for alternative activities in relentlessly urban Beijing or Seoul are lacking.Or that China’s brave new world requires many families to live apart and where their only communication is via the internet. For the totalitarian minded, It’s also a useful excuse for limiting internet access.

And even if none of the above objections were valid, the internet is not simply one thing to be addicted to, but rather a portal to allow a wide range of activities.As a media it can be no more addictive than a book, or as part of the social milieu it can no more be addictive than the air to breathe (that is, it is a category error – see comment below).And the question must be asked of how much additional information is convey in an IAD diagnosis, when the behaviour could more usefully be described in terms of more established diagnoses.

Over £50 000 has been raised for an advertisement campaign on London buses intended to spread the word of unbelievers.The slogan, ‘There’s probably no God, now stop worrying and enjoy your life’, whist not being particularly catchy, is interesting.

In dissecting it, there’s a connection implied between religion and anxiety, a plea made to end introspection concerning speculation of the existence of a supreme being – as if this enquiry was somehow reprehensible – and an implication made that religion is the root of all our problems, as if the only thing standing between mortals and earthly contentment is religious belief.

This small campaign, whether your agree with it or not, or whether like me you consider it only marginally less prescriptive than the religious advertisements it seeks to combat, at least feels like a levelling.The campaign, funded mostly by small contributions, represents a rare right to reply.As during so much of our day, we are assaulted with large advertisements, and beyond graffiti, there is scant ability to register our dissent or disapproval.

But what part does a religion belief play in mental well-being?

The best insight I’ve found on this is a 1999 literature review of 80 studies concerning the association of depression and religion.This suggests that people who are involved frequently in organized religion and who highly value their religious faith for ‘intrinsic reasons’ are at substantially reduced risk of depressive disorder and depressive symptoms. They also appear to recover more quickly from depressive episodes and are less likely to become depressed over time. On the other hand the authors say that people who are involved in religion for reasons of ‘self-interest’ are at a higher risk for depressive symptoms.

Two groups – Jews and people who are not affiliated with a religion – are at an elevated risk of depression and depressive symptoms and the authors speculate that these effects are ‘a result of trade-offs in how latent predispositions for psychopathology are expressed in certain religious cultures’.*

Private religious activity and particular religious beliefs, which probably equates to people saying that they are ‘spiritual but not religious’ (we’ve all met them), appear to bear no reliable relationship with depression.

The review states that these associations are modest, but consistent, and does flag up weaknesses in the evidence base. In terms of validity it concerns me that the difference between religious believers who have intrinsic and extrinsic beliefs and their relative vulnerabilities may essentially be a proxy for the personality types amassing under these banners.

* I’ve thought about this last sentence and I’m not entirely sure what it means.Can you help?

I did swear to myself recently that I wouldn’t write any more posts about celebrities and their mental health problems, but then David Duchovnystarted saying he’s a sex addict and I have a problem with this.

The word ‘addiction’ hasn’t an exact or agreed definition either within common or medical usage, but is normally applied to the use of psychoactive substances, and, called dependence syndrome; its use in psychiatry implies:

A cluster of psychological, behavioural and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours which once had a greater value.

For the diagnosis to be robust there needs to be accompanying evidence of difficulties in controlling behaviour despite clear evidence of consequences, and increased tolerance to the substance, a withdrawal syndrome and progressive neglect of alternative pleasures.A good example would be someone who is dependent upon alcohol; you can readily observe the effects, a complete deterioration of self control in pursuit of drunkenness, on a street near you.

An obsession with sex shares few of these characteristics, and its classification as a disorder offers a comforting cushion for those whose behaviour has landed them into trouble.With this narrative, wherein greedy behaviour is rebranded as a disorder, the afflicted can neatly sidestep responsibility and jump straight into the sick role.

Regrettably the more this line is trotted out by popular press, supported by some psychiatrist and psychologists, the more the approach is normalized and what develops is a popular narrative and language for describing behaviour in pseudo-medical terms that which would once have been viewed as an issue of self control and personal failing.

(I can’t immediately find out what happened to F20.7 – maybe it suffered the same fate as floor number 13 in New York skyscrapers)

The aetiology of schizophrenia is unknown; as this is the case we are forced to define schizophrenia on the basis of a number of symptoms which appear together sufficiently frequently to merit a grouping.In this way schizophrenia is a syndrome rather than a disease.A disease is a disorder with a specific cause and recognizable signs and symptoms whereas a syndrome is combination of signs and/or symptoms that form a distinct clinical picture.The ICD-10 classification system deliberately avoids including aetiology in its definition.

Schizophrenia is a disorder which covers a wide range of cognitive, emotional and behavioural disturbances; there is disintegration in the process of thinking, of contact with reality and a pattern of emotional unresponsiveness.

ICD-10 puts it nicely:

The schizophrenia disorders are characterized in general by fundamental and characteristic distortions of thinking and perception and by inappropriate or blunted affect.

There is no one sign that ‘guarantees’ a diagnosis of schizophrenia.For instance many of the characteristic symptoms of schizophrenia can occur during a manic phase of bipolar disorder or during psychotic depression.However the following ‘fundamental and characteristic disorders of thinking and perception’ are considered to have special importance in the diagnosis of schizophrenia.They are based on Schneider’s first rank symptoms, proposed in 1959 and are:

(c) hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing the patient among themselves, or other types of hallucinatory voices coming from some part of the body;

(d) persistent delusions of other kinds that are culturally inappropriate and completely impossible, such as religious or political identity, or superhuman powers and abilities (e.g. being able to control the weather, or being in communication with aliens from another world);

(e) persistent hallucinations in any modality, when accompanied either by fleeting or half-formed delusions without clear affective content, or by persistent over-valued ideas, or when occurring every day for weeks or months on end;

(f) breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech, or neologisms;

(h) “negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses, usually resulting in social withdrawal and lowering of social performance; it must be clear that these are not due to depression or to neuroleptic medication;

(i) a significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.

(Source of (a)-(i) ICD-10)

The final thing to say is that the conception of schizophrenia is to a certain extent historical and many textbooks choose to explain schizophrenia as a disorder with reference to the history of its classification.The term itself was Bleuler introduced the term in his 1911 book ‘Dementia praecox or the group of schizophrenias’

On closer inspection, it’s less an article, more an advertorial for a book called ‘Beating stress, anxiety and depression’ by Jane Plant and Janet Stephenson. The article says that the book is ‘new’ but the amazon.co.uk page says that it came out at the beginning of May this year. I can only imagine that they were short of copy and rehashed a press release that they found knocking around the office.

Be this as it may, this is the sort of thing that catches my eye. The introduction is available for perusal online, and Plant and Stephenson say some sensible things – like advising us to ignore celebrity culture – but I am concerned about some of the things they say particularly when they assert that levels of neurotransmitters should be assessed in patients suffering from depression. The neurotransmitter hypothesis is problematic, as discussed by Badscience.net and Mindhacks.com, and this sort of test are likely to be more expensive than meaningful.

Daily Mail article on the same book title: ‘How the wrong drugs could be causing your depression’.

Best read it before I comment further. If anyone has read it and would like leave a comment below I would be most grateful.

What strikes you most about Marsh when you meet her is not her pleasure at the unexpected turn her life has taken, but her implacable anger…..(about four paragraphs)….I’ve lost count of the number of times youth workers and criminologists alike have made the connection, as they discuss knife crime, between low self-esteem and anger. Well, there is an awful lot of anger among those who participate in reality TV, the majority of which, it seems to me, is the result of low self-esteem, and Marsh is no exception.

Frontier Psychiatrist has just been on holiday to the Outer Hebrides. Anyone who reads this blog will know that I am a devotee of theguardian newspaper. I normally read this online, but as a holiday treat whilst on the Isle of Harris-North Uist ferry I was reading a printed copy. A normally relaxed gentleman, upon reading this article by Pamela Stephenson Connolly I came close to leaving the comfort of the ferry cabin to go onto the deck and shake my fist at the waves.

Stephenson Connolly writes a column for theguardian’s G2 section on a regular basis as a sort of sexual agony aunt. Here was this week’s question:

‘My boyfriend is an outgoing type, always the life of the party. Even when we’re alone he wants to joke around. I love him, and sex with him is satisfying when we finish what we start. However, when we’re making love he is easily distracted. It could be the sound of someone moving around in the next flat, or noise outside, but pretty soon he loses his erection. Is this normal? How can I keep his mind on the job?’

To which Stephenson Connolly, ‘a clinical psychologist and psychotherapist who specialises in treating sexual disorders’, replies:

‘It is "normal" – for someone whose brain is wired in such a way that paying attention to one thing at a time is challenging. Your boyfriend may have Attention Deficit Hyperactivity Disorder (ADHD), meaning that he has difficulty filtering out sounds and other stimuli that are competing for his attention.

Don’t take it personally.

You should suggest he be evaluated and treated for ADHD, while remembering that he is probably a bright and creative person, who could do with your help in staying on-task.

Imagine what it’s like to be inside his head. Think carefully about your lovemaking environment and create a place with a minimum of stimuli. Consider darkening the room, eliminating telephones and TV and even installing sound-proofing or using noise-cancelling headphones. If thoughts begin to distract him, encourage him to let you know so you can help to bring him back with your voice, touch or whatever else may work. You will need to experiment a bit. Praise and reward his efforts to stay focused – you will reap the benefits.’

Although she almost says something sensible at the end, it’s hard to believe that someone who claims the expertise of Stephenson Connolly could write something like this (budding psychiatrists, write down your own reasons for Stephenson Connolly’s idiocy and then read the rest of the article – if you can think of any that I don’t mention then please add a comment).

Stephenson Connolly is suggesting a diagnosis of ADHD on extremely flimsy evidence even for a newspaper column. She should know that ADHD diagnostic guidelines suggest that symptoms applicable to this sort of diagnosis should be present in more than one situation, for instance at home and at school. Our man has his distractability in only one very specific situation. She should also know that distractability, which is the only symptom mentioned in the ‘letter’, is far from the only symptoms shown by ADHD sufferers. ‘Always joking around’ hardly counts; what about disinhibition in social relationships, recklessness in situations involving some danger, and flouting of social rules, to name but three? ADHD can be diagnosed de novo in adulthood, but she should at least mention the possibility of childhood symptoms.

But let’s be charitable and assume that, although unlikely, ADHD is a possibility here. It’s certainly a Zebra:

Zebra (noun): a very unlikely diagnosis where a more common disease would be more likely to cause a patient’s symptoms – from the common admonition that "if you hear hoofbeats, think horses, not zebras"

Is it not rather more likely that the reason that this man is unable to complete sex with his girlfriend because he isn’t very sexually interested in her in the first place? Or maybe he’s homosexual? Is not Stephenson Connolly guilty of grossly medicalizing what is in fact a social problem? Why bring in mental health at all?

Sometimes after days spent sorting out my patients’ housing problems or imparting common sense where seemingly there is none, I sometimes wonder what psychiatrists are for – but here’s one of the reasons, stopping people who don’t know what they’re talking about, but have a shiny new textbook and an over zealous approach, giving patients potentially stigmatizing diagnostic labels on very limited evidence.